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General NPI Number Information
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NPI Number | 1659529287
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Entity Type | Organization
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Legal Business Name | COLUMBIA RIVER MEDICAL CLINIC, P.C.
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Dates
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Enumeration Date | 09/08/2008
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Last Update Date | 09/08/2008
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Provider Practice Location Address
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Address Line | 1615 E 12TH ST SUITE 100
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City | THE DALLES
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State | OR
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Zip | 97058-3212
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Country | US
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Telephone | 541-296-1919
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Fax | 541-296-2253
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Provider Business Mailing Address
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Address Line | PO BOX 1580
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City | THE DALLES
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State | OR
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Zip | 97058-8004
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Country | US
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Telephone | 541-296-1919
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Fax | 541-296-2253
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Authorized Official
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Title or Position | OWNER
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Name | MARK DENNIS CZARNECKI
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Credential | DO
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Telephone | 541-296-1919
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 15400DO
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License Number State | OR
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